Presented at AIDS 2010 in Vienna - Austria

Do integrated services perform better than specialist sites at meeting the SRH needs of people living with HIV?

1) Study background & aimsMuch attention has been paid to the clinical management of HIV,yet little is understood about the impact of differences servicemodels on client experiences and satisfaction. The integration ofsexual and reproductive health (SRH) with HIV services hasbecome a policy focus in recent years, and is being widelypromoted by international health agencies. Studies suggestintegration can increase access to sexual and reproductive health(SRH) services and may be less stigmatising for clients since care isdelivered in a context unassociated with HIV/AIDS. 1,2

A mixed methods study is being conducted in four HIV clinics inone town (Manzini) in Swaziland to explore the process of healthcare delivery at stand-alone and integrated HIV sites (see Figure 1).The larger study asks whether integrating HIV and SRH services isan effective model of health care for HIV patients, through acomparative analysis of integrated and stand-alone HIV servicedelivery models.

This poster presents findings from the second part of the study, in-depth interviews with clients. The sub-study aim was to explorethe sexual and reproductive needs of clients (people living withHIV (PLWH) as they initiate ART (in particular family planning (FP)needs); to examine service responses to these needs within thedifferent models of care; and to explore perceptions towardsclinic-based stigmatisation.

Church K,1 Fakudze P,1 Masuku S,2 Mayhew S,1 for the Integra research team3

2) Methods• In-depth interviews with clients from 4 clinics

in Manzini, Swaziland that offer antiretroviral therapy (ART) (see Table below).

• Clients were interviewed at 3 points in time: i) on the day of ART initiation; ii) 2 months after ART initiation; iii) 6 months after ART initiation.

• 22 clients were interviewed at Round 1, and 16 of these were interviewed at Rounds 2 and 3. Overall, 6 clients were lost to follow-up due to death or loss of contact.

• Semi-structured interviews were conducted in SiSwati, recorded, transcribed and translated into English.

• Thematic analysis was conducted using Atlas TI with a coding framework developed using both deductive and inductive methods that was continuously revised through the analysis process. Summary findings, concepts and quotes were charted according to theme and clinic type to aid the analysis.

5) Discussion & conclusions• Integrated sites do not seem to be performing better than stand-alone clinics in addressing

the widespread unmet SRH needs that were identified in this group. This may be due to the standardised approach to ART initiation, in which post-ART initiation protocols on FP are lacking. The failed use of internal referral to FP rooms or counsellors warrants further investigation, but suggests that SRH counselling may need to be conducted onsite by an ART provider to be done successfully.

• It is encouraging that ART services seem to be successful in promoting condom use. This highlights the positive role that health services can play in HIV prevention through sustained contact with health services. However, condom promotion may be entirely displacing counselling on other FP methods, and thus greater attention is needed on dual protection.

• Integrated services may not be successful in reducing stigma when confidentiality is breeched in waiting and reception areas. The social support found from other HIV patients in waiting areas at stand-alone sites is important and capitalized on by all service models. The reluctance of clients at stand-alone sites to support integration with health services underlines their satisfaction with this model of care.

A follow up quantitative survey has followed this study, investigating the response of the different models of care to client SRH needs. Contact authors for more details.

Partner organizations in the Integra Project:

1 Centre for Population Studies, London School of Hygiene and Tropical Medicine (LSHTM), UK (Contact: kathryn.church@lshtm.ac.uk )2 Family Life Association of Swaziland (FLAS), Manzini, Swaziland 3 The Integra project is a partnership between the International Planned Parenthood Federation, LSHTM, and the Population Council.

References:

1. Church, K and Mayhew SH (2009) Integration of STI and HIV prevention, care, and treatment into family planning services: a review of the literature. Studies in Family Planning 40(3): 171-186.

2. Bradley, H, Gillespie D, et al. (2009) Providing family planning in Ethiopian voluntary HIV counseling and testing facilities: client, counselor and facility-level considerations. AIDS 23: S105-S114

The Integra Project is a partnership between IPPF, LSHTM and Population Council to assess the benefits & costs of different models of integration of HIV and SRH services in Swaziland, Kenya and Malawi. Running from 2008-2012, it aims to (a) determine the benefits of different integrated models; (b) determine the impact of different integrated services on changes in HIV risk-behaviour; HIV related stigma and unintended pregnancies; (c) establish the efficiency of using different operational models for deliveringintegrated services; and (d) increase utilization of research findings by policy and program decision makers through involvement of and dissemination to key stakeholders.

Related AIDS 2010 Posters (Integra project)

A. SRH clinic:

Integrated SRH-HIV

B. PHC clinic: Integrated PHC - HIV

D. ART clinic:

Stand-alone HIV service

C. District hospital:

Stand-alone ART unit

Figure 1: The Four Study Clinics, Manzini, Swaziland

Clinic A: A SRH clinic where ART has been integrated. 3 providers focus on ART and can deliver all SRH services (PROVIDER-LEVEL INTEGRATION).

Clinic B: A ‘public health unit’ (primary care in an urban area) where ART has been integrated in two rooms. Clients can visit other rooms for SRH services(FACILITY-LEVEL INTEGRATION)

Swaziland

Clinic C: An ART clinic located on the campus of a district hospital. Clients can be referred to other buildings/depts for other SRH services (STAND-ALONE ART UNIT)

Clinic D: An HIV clinic delivering ART and VCT services. Clients are referred elsewhere for SRH services (STAND-ALONE HIV SERVICE)

Experiences of a qualitative cohort of HIV clients at ART initiation in Swaziland

4) Results part 2: The servicesService response: success in positive prevention & pregnancy counselling

• Most participants had been counselled on multiple occasions to use condoms. Several clients who had been inconsistent or failed condom users in the past now felt empowered to be a condom user.

• Most participants had been counselled about pregnancy, and we found no reports of negative attitudes among providers about future child-bearing with HIV.

But responses to client SRH needs remain inadequate at all sites

• Several of those in need of FP services had failed to discuss it with providers, suggesting that services could play a much more active role in promoting FP services:

R: there is one thing I want the doctor to help me with, coz I have a problem with the injection *FP+ and I don’t want to do tubal ligation and so I want to ask him what he can help me with *…+ so that I won’t have another babyI: okay, but why didn’t you discuss it with him?R: I’m still thinking as I have so many thoughts,*...+ I want to ask my doctor *about the implants+, maybe he can explain better and maybe see if can do it coz I’m really afraid” (female, integrated clinic, 6 months following ART initiation)

• FP counselling is focused at ART initiation (adherence counselling), the point where clients have low libido and are highly preoccupied with other multiple and complex health issues.

• While all clients at all sites reported continued condom counselling, clients at the 2 integrated sites reported more repeat FP counselling following ART initiation.

Service fragmentation may be inhibiting integration goals

• Some clients at integrated sites had been referred internally for FP, but had failed to attend the service, indicating that ‘facility-level’ integration may be problematic.

• Clients reported service fragmentation across all sites. This included fragmentation of HIV care among nurses, doctors, counsellors, lab technicians, and pharmacists; but also for access to other SRH services. Pregnant women seem to often suffer most from service fragmentation: Figure 2 shows a service use trajectory of a woman at an integrated site who had failed to coordinate her pregnancy and ART visits:

Stand-alone clinics may not be more stigmatizing than integrated sites

• While some clients at integrated sites felt the service was confidential and preferred being mixed with other clients so they wouldn’t feel ashamed, others reported occasions where their status had been disclosed or felt their privacy was compromised:

“I think I’m used to *the waiting room+ now … at first I was really scared, they would call us like ‘those who came to get pills’, or ‘those who are starting’ … and I was not happy about that” (female client, integrated clinic)

• Clients at stand-alone sites often found companionship in the waiting room and appreciated being in an environment only for PLWH:

“I haven’t told anyone *about my status+ I only tell those that I find at the clinic when I go collect my pills, they talk about their situations and I also find myself sharing mine” (female, stand-alone clinic)

Clients are generally satisfied with (their own) treatment site

• We round high levels of client satisfaction in this group. Several compared care in their HIV clinic favourably to other Swazi health services. Clients seem to value affective elements of quality of care over the specific model of service delivery (e.g. waiting times, friendliness of providers, perceived trust in the providers). Those at integrated sites appreciate privacy and access to a range of services; those at specialist sites appreciate companionship from other HIV patients.

3) Results part 1: The clientMany clients have unmet SRH needs, which change over time on ART

• There were substantial reported unmet needs for SRH services across all sites, both integrated and stand-alone, including many cases of unintended pregnancies and limited use of effective contraceptive methods in those not desiring a pregnancy.

• Having an unintended pregnancy while HIV+ had profound consequences for some participants:

“I: I mean, having a child like the one you have now…how do you feel?R: it’s painful because I hadn’t expected him, I thought I had stopped with the one before this one, I hadn’t planned for him which is why I get tears in my eyes all the time when I think what will happen with the child, and when I found out he’s HIV positive it got me thinking, that how are the other children going to take it if they find out he’s positive” (female, integrated clinic)

• Several participants had stopped use of effective contraceptive methods, some due to side-effects, some due to the HIV illness -- this despite the fact that most respondents reported NOT wanting more children:

• Most clients reported low sexual activity at the time of ART initiation; a disinterest in sex coupled with multiple illness problems meant that FP was not an important consideration for clients at that time. However, most regained libido over the subsequent 6 months as their health improved. Most of those with concerns about libido had not discussed them with their providers.

An over-reliance on condoms?

• Most clients were relying on condoms for contraceptive protection and many felt strongly that condoms were the only effective FP method for PLWH.

“Since I tested I haven’t been back on the injection, because I used to do it back in 2005 when I used to sleep without a condom, but now that I’ve tested I haven’t gone back to family planning, I’ve decided to use the condom” (Female, stand-alone clinic)

• Other methods of FP were considered by some participants only appropriate for those with children:

“I: what [FP} method do you think you’d use?R: I would go to the nurse to ask… but I think I would just use condoms, not the other family planning methods, because I don’t see why I would use them when I don’t have a child” (female client, integrated clinic)

• However, while some were happy to rely on condoms, others were more fearful about their efficacy, in particular those in sero-discordant relationships. Many also admitted problems in consistent condom use, even when they had brought their partner to the clinic for counselling. Those not in relationships feared entering new relationships where they would have to disclose their status and negotiate condom use.

“I just keep thinking about a situation where I meet another person and like them a lot, but then find out that they don’t want to use a condom with me. What then? Or when I have to tell them about my status. I’m just not ready for that right now“ (female, integrated clinic, 6 months after treatment initiation)

Clients desire both integrated and ‘specialist’ care

• Many clients across all sites indicated a preference for further service integration, and complained of having to visit multiple rooms or facilities to receive the package of services they desired.

• However, many were aware of the implications of receiving a broader package of care, specifically the additional waiting time that might be required, and felt fearful of keeping others waiting.

• Most of those at stand-alone sites were against the idea of integrating HIV care with other health services, and felt health care provision was more efficient at their specialist site.

Characteristic Category No.

Clinic Clinic A

Clinic B

Clinic C

Clinic D

6

6

5

5

Sex Male

Female

7

15

Age 20-24

25-29

30-34

35-39

≥ 40

2

6

9

3

2

Relationship

status

Single

Has partner living

elsewhere

Living with partner

Married

5

8

2

7

Education Primary

Secondary

College or above

Adult education

7

12

2

1

Pregnancy

status (f)

Pregnant

Not pregnant

5

10

Acknowledgements: Funding for the research came from: Economic and Social Research Council & Medical Research Council (UK), and from the Bill & Melinda Gates Foundation.

Fig 2: Service use trajectory of pregnant client (clinic B), Months 1-3 ART

• THPE0770: Qualitative study with HIV service providers (part of this ART clinic case study in Manzini, Swaziland)

• MOPE1038: Policy study on integration in Swaziland

• THPE0822: Community survey data on demand for integrated services

• MOPE0853 , CDE1159, CDE1311: Economics evaluations